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Does Your Service Report Medical Errors To THE PATIENT ?


flamingemt2011

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I found this story today and it made me wonder what the rest of your services did:

http://web.orange.co.uk/article/news/widow_accuses_nhs_over_paramedic_treatment

I always reported medication errors to the receiving nurses, but I know many that did not (especially if there was no harm to patient --- gave atrovent instead of albuterol).

But over the years I would occassionally hear a rumor that so and so was suspended after a review of treatment on a particular call, but I do not think the patient or patient's family was ever told of the mistakes.

What do you think, should all errors be reported to the patient regardless of how insignificant, or should it be swept under the rug like in the above article ?

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Not biased, if anything I would say I am part of the problem if I were honest. I have watched many errors be swept under the rug in medicine generally throughout my career: Wrong diagnosis, wrong treatment, lack of treatment, medication errors, failure to treat. I am sure I am not the only one who has witnessed this problem.

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I won't pretend to know British law but here in the US we do have M&M conferences that are protected from legal action. Anything that is said and done is confidential and cannot be used in a court of law. Maybe the situation is the same over there. It sounds like the medic was incompetent anyways.

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Wrong diagnosis, wrong treatment, lack of treatment, medication errors, failure to treat. I am sure I am not the only one who has witnessed this problem.

I didn't realize medicine was so cut and dry.

Sounds like the medic refused online orders. Big problem. As far as reporting errors, I'd tell the receiving facility and document. I am not the one to call the family. My pockets have holes in them as it is.

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I think it's a slippery slope. It would be good to be able to track errors for the sake of altering education and mitigating future errors of the same flavor, certainly.

But EMS, and I guess medicine in general, is not cut and dried. Mistakes are going to be made and it's vital that we are all allowed to learn from them. Should there be severe consequences to admitting those mistakes then the reporting will stop and EMS will plummet even further down the educational/competency ladder than it is now.

There is also the cost/benefit to the family members. What did this woman gain by this knowledge, assuming it didn't withhold from her an ability to sue. She is now suffering much more than she was before. She likely has none of the specific educational background and experience necissary to understand the errors made, whether or not they should have been considered acceptable, what the errors mean in the context of her husband surviving. It sounds as if what she heard was, "If these errors hadn't been made he would still be with me now." It's a shame that she was tormented with that when there is every chance that it is untrue.

There is just so little that goes on that would benefit the family knowing. When I did my first chest decompression I didn't realize that the needle I was using came in three parts instead of two like the ones that I had practiced with in school. I darted his chest, pulled the top off, didn't hear any air, thought, "Hell, I wonder if that was the wrong choice." and went about my work. I was doing CPR by the time I got to the hospital, noticed that the cath seemed to be leaning, tried to move it so that it wouldn't kink..and pulled the friggin' needle out to the sound of hissing air.

I held it up in front of the doc, he knew of course exactly what it meant, and we went back to the arrest. Afterwards I freaked out a little bit when I saw him replace it and have an xray taken, as during CPR we'd started getting blood up the tube. Only then did it occur to me that not having removed it may not have only retarded his resus, but might also have chopped up part of his lung. The doc came to me later and said, "yeah, it wasn't the needle, his lung was cut by a broken rib." Of course by that time I'd already penciled out a new career path outside of EMS.

I friggin' hate that story for the part I played. But I think that the doc played the best possible part. Had he found that the needle had been the culprit I believe he would have, and I would have expected him to, reported the incident to my employer and whoever else was appropriate. I ended up admitting it in a call review and got myself jammed up anyway with a letter in my file, but, you know... :-)

The point I'm trying to make in this novella, is that though there was an error it didn't ultimately effect the patient outcome (We got pulses back, few him out, but he dies soon after). I learned my lesson forever, as does anyone that I'm put in the dubious position of helping to educated, so the system is better, and there is no real benefit to the widow in knowing each detail of the attempts to save her husband, either positive or negative unless knowing will give he a right to compensation.

So, I guess what I'm saying is, 'sweeping under the rug' and the attempt to hide from liability as the article seems to imply = Bad. Withholding information that is likely part of the learning and practice of emergency medicine when no real malfeasance is in play = realistic and productive, though not sure if it's good.

Dwayne

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I fully understand the reasons why we would not tell on ourselves, but if it was your family member, what would you want ? And no, I am not talking about pushing atropine instead of Epi on an arrest, I mean a serious error that could or did impact the patient.

When car makers make a design mistake, they have to admit it to us, perform a recall, and fix the problem at their expense. Is our profession less important that an auto manufacturer ?

I am not proud of the errors that I did not report, but now that I am more mature, I can say that ALL errors should be reported to the patient, if we are truly professional and are patient advocates. To not do so is unprofessional and makes you like the cook who drops your food on a nasty floor, and serves it to you anyway.

MY error: Chest pain patient in Bigeminy, started Lidocaine and Lidocaine drip, opened line wide open to check flow, patient vomited, got side tracked, left the Lidocaine wide open by mistake, patient had a seizure a few minutes later, looked up, Lidocaine drip bag empty. Patient lived, but I never told a sole (hung second bad of Lidocaine, told partner I contaminated the first.

Edited by flamingemt2011
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